Cross-sectional study of the influence of gestational hyperglycemia associated with urinary incontinence on quality of life

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Women’s Health Care

Santini et al., J Women’s Health Care 2014, 4:1 http://dx.doi.org/10.4172/2167-0420.1000214

Volume 4 • Issue 1 • 1000214 J Women’s Health Care

ISSN: 2167-0420 JWHC, an open access journal

Open Access Research Article

Cross-Sectional Study of the Influence of Gestational Hyperglycemia

Associated With Urinary Incontinence on Quality Of Life

Ana Carolina Monteiro Santini1_{*, Angélica Mércia Pascon Barbosa}3_{, Vanessa de Oliveira Sousa}1_{, Liamara Cavalcante de Assis}1_{, Luana}

Schineider Vianna1_{, Iracema Mattos Paranhos Calderon}4 _{and Adriano Dias}2_*

1_{Physiotherapist, Postgraduate, Department of Gynecology, Obstetrics and Mastology of Botucatu Medical School- São Paulo State University/UNESP, Brazil} 2_{Epidemiologist, Ph.D. Assistant Professor, Postgraduation Program in Gynecology, Obstetrics and Mastology of Botucatu Medical School- São Paulo State University/} UNESP, Brazil

3_{Physiotherapist, Ph.D. Assistant Professor, School of Philosophy and Sciences-São Paulo State University/UNESP, Brazil}

4_{Obstetrician, Titular Professor Postgraduation Program in Gynecology, Obstetrics and Mastology of Botucatu Medical School- São Paulo State University/UNESP, Brazil}

Abstract

During pregnancy, the prevalence of Urinary Incontinence (UI) is higher adversely impacting quality of life. Both Gestational Diabetes (GDM) and mild hyperglycemia have been associated with increased risk of UI. However, UI

inluence on quality of life is still poorly understood. The objective of this study was to assess the impact of UI on the

quality of life of women with GDM. Method: Cross-sectional study including pregnant women allocated into 2 groups:

Normoglycemic (NG) or Hyperglycemic/GDM (HG). All women classiied as incontinent were asked to respond to

the King’s Health Questionnaire (KHQ). Results: Of the 102 pregnant women enrolled, 69 were NG (67.6%) and 33

were HG (32.4%). UI prevalence was 55.9%. HG scores were lower for all KHQ domains with signiicant differences

between groups regarding the scores for KHQ domains general health perception, UI impact, personal relationships emotions, and sleep/energy (p<0.05). Conclusions: UI impact was higher on pregnant women with hyperglycemia and GDM.

*Corresponding author: Ana Carolina Monteiro Santini, Botucatu Medical School UNESP - Univ Estadual Paulista, 1919, Coronel Fonseca St, Botucatu, São Paulo,

Brazil, Tel: +55(14)96174711; E-mail: acmsantini@gmail.com; adias@fmb.unesp.br

Received September 27, 2014; Accepted December 22, 2014; Published

December 29, 2014

Citation: Santini ACM, Barbosa AMP, de Oliveira Sousa V, de Assis LC, Vianna LS, et al. (2014) Cross-Sectional Study of the Inluence of Gestational Hyperglycemia Associated With Urinary Incontinence on Quality Of Life. J Women’s Health Care 4: 214. doi:10.4172/2167-0420.1000214

Copyright: © 2014 Santini ACM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Keywords:

Gestational diabetes mellitus; Urinary incontinence; Quality of life

Introduction

Urinary Incontinence (UI) is deined by the International Continence Society (ICS) as the involuntary loss of urine that represents a hygienic or social problem to the individual [1]. Despite not being life-threatening, UI afects women on their daily living activities, social interactions, interpersonal and sexual relationships, careers, and psychological wellbeing thereby adversely impacting their quality of life [2-10]. he etiology of UI is multifactorial, but hyperglycemic disorders and pregnancy are recognized as important risk factors. UI prevalence and severity are signiicantly higher during pregnancy and in women with diabetes mellitus or a history of gestational diabetes mellitus (GDM) [11-16].

GDM is any degree of glucose intolerance with onset or irst recognition during pregnancy [17,18], a period characterized as a diabetogenic state [19] marked by progressive metabolic and hormonal changes [20]. Just like UI, GDM may also negatively impact quality of life. In a survey conducted in 10 Italian centers specialized in the care of pregnant women with diabetes, Lapolla et al. observed that the diagnosis of GDM caused anxiety; one-third of women feared their child could contract diabetes at delivery and/or have congenital malformations [21].

Barbosa et al. [13], in a study of the inter-relationships among GDM, pelvic loor dysfunction and UI, reported that UI prevalence two years ater childbirth was higher in women with a history of GDM. Kim et al. [14] found that 49% of 228 women with a history of GDM reported weekly or more frequent incontinence during pregnancy. Chuang et al. [22], investigating the occurrence of all types of UI and type-speciic risk factors in the third trimester of gestation and at four time-points over 2 years ater childbirth in 6653 women consecutively recruited, concluded that GDM was an independent risk factor for postpartum UI, and that quality of life was generally poorer among women with GDM.

Quality of life is an individual’s perception of their position in life in the context of the culture and value systems in which they live

and in relation to their goals, expectations, standards and concerns [23]. Studies have demonstrated clinical associations between UI and hyperglycemia during pregnancy [13,14]. However, the inluence of this condition on quality of life is still poorly understood. hus, the objective of this study was to assess the impact of UI on the quality of life of women with GDM.

Methods

his cross-sectional study included all pregnant women at 24-28 weeks of gestation receiving prenatal care at the Pregnancy and Diabetes Center of Botucatu Medical School, São Paulo State University/UNESP between December 2009 and December 2010. he study was approved by the local Research Ethics Committee (#426-08), and written informed consent was obtained from all subjects.

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Pregnant women with a history of previous GDM, pre-gestational type 1 or type 2 diabetes mellitus, systemic arterial hypertension or gestational hypertensive disorders, pre-gestational UI, neuromuscular diseases, cognitive disorders, previous or current twin pregnancy, vaginal inlammations and infections, age under 18 years without parental consent, or refusing to participate, were not included in the study.

Private interviews were conducted for the gathering of demographic, clinical, and obstetric data, including information on UI symptoms. Women with any complaint of involuntary urinary loss were considered incontinent [1]. Previously validated questions adapted from Rohr et al. [25], were used to classify UI as “urge”, “mixed”, or “stress”. Other urinary symptoms such as voiding frequency, nocturia, nocturnal enuresis (involuntary voiding of urine during sleep), and incontinence during sexual intercourse were also investigated [1].

All women classiied as incontinent were asked to respond to the Portuguese version of the King’s Health Questionnaire (KHQ) [26]. he KHQ was developed in 1997 for the assessment of quality of life in patients with urinary incontinence by Kelleher et al. [3]. It has 21 items representing eight domains: general health perception, UI impact, role limitations, physical limitations, social limitations, personal relationships, emotions, and sleep/energy. he KHQ also contains two other independent scales that evaluate UI severity (severity measures), as well as urinary symptoms. hese scales ofer the following choices: “not at all”, “a little”, “moderately” and “a lot”; or “never”, “sometimes”, “oten” and “always”. Exceptions are the domains general health perception (“very good”, “good”, “fair”, “bad” and “very bad”) and personal relationships (“not applicable”, “not at all”, “a little”, “moderately” and “a lot”), which present ive choices. Rather than an overall score, the KHQ provides a 0-100 score for each domain where higher scores indicate worse quality of life related to that domain [26].

Taking into account the proportion of incontinence among diabetic women (40%) and the probability of incontinence occurrence during pregnancy (45%) reported in the literature, and assuming a type I error of 5% and a type II error of 20%, the minimum sample size was estimated as 33 pregnant women per group.

Based on an initial exploratory data analysis, categorical variables were expressed as proportions and continuous variables, which did not follow a normal distribution, were reported as medians. Proportions and medians were compared by the Chi-square test and the Mann-Whitney test, respectively. Statistical data analysis was performed using IBM SPSS Statistics, v.20.0, with signiicance level set at 5%.

Results

Of the 102 pregnant women enrolled, 69 were NG (67.6%) and 33 were HG (32.4%). Median age among NG and HG participants was 26 and 31 years, respectively. Gestational age signiicantly difered between groups. Most women were married, pregnant for the second time, had completed high school, and reported no regular alcohol consumption or smoking. he prevalence of UI deined as “Have you ever experienced involuntary urine loss?” was 55.9%.

he KHQ was administered to 57 incontinent women - 37 from the HG group (53.6%) and 20 from the NG group (60.6%). his diference in the proportion of UI occurrence between groups was not statistically signiicant.

Table 1 shows that there were signiicant diferences between groups regarding the scores for KHQ domain scores general health perception, UI impact, personal relationships emotions, and sleep/energy whereas

no signiicant diferences were found in role limitations, physical limitations, social limitations and severity measures. It is worth of note that HG scores were lower for all KHQ domains.

Discussion

Rather than diagnosing UI, this study aimed at assessing if UI symptoms afected the quality of life of pregnant women with GDM. Urodynamic assessment is considered the gold standard for a precise diagnosis [27,28], particularly when a surgical approach is required. However, when conservative strategies are adopted, there is still debate about its use because, as stated by the ICS [1], self-reported urine loss is a reliable measure of the symptom [26].

Consistently with other reports [15,16,29-33], the prevalence of UI was high among the pregnant women participating in this study, with no signiicant diference between groups.

he assessment of the KHQ general health perception domain showed that NG women rated their health status at the moment as “good”, whereas women with GDM classiied their status as “regular”. his inding is in accordance with Kim et al. [23], who found that women with a history of GDM had poorer self-rated health than women without it.

In response to the question “how much do you think your bladder problem afects your life?”, most NG women answered “not at all” while HG women responded “a little”. his is in agreement with Dolan et al. [34], who used the KHQ to establish the prevalence and efect of urinary incontinence on quality of life during pregnancy and ater parturition. hey concluded that most women with urinary incontinence experience minimal impact on quality of life during pregnancy. According to Santos et al. [5], women describe the discomfort caused by UI during pregnancy as milder than that experienced before pregnancy probably because UI is considered to be a natural consequence of pregnancy, and the appearance of other uncomfortable symptoms may lead them to rate the impact of urine loss as minor.

Kocaoz et al. [35], in a study of 393 pregnant women, found that their quality of life was either unafected or very little afected by urinary incontinence. In addition, they also observed that only a few of those women sought help from a healthcare professional [36-38].

Other investigators demonstrated that only a minority of UI patients seek help for their condition, and that when they do it, their major concern is the odor of urine [39-41]. his concern was also reported by both NG and HG women participating in our study.

In our study, pregnant women from both groups rated the impact of urinary incontinence as minor. However, several studies have suggested that incontinence in pregnancy may be a risk for incontinence later in

HG (n=20) NG (n=37)

Valor-p* p25 p50 p75 p25 p50 p75

General health perception 25.00 25.00 50.00 0.00 25.00 25.00 0.001

UI impact 33.33 33.33 66.67 33.33 33.33 33.33 0.002

Role limitations 8.33 33.33 58.34 0.00 0.00 33.33 0.054

Physical limitations 0.00 33.33 58.34 0.00 16.67 33.33 0.118

Social limitations 11.11 19.45 45.83 0.00 16.67 27.78 0.064

Personal relationships 0.00 0.00 29.17 0.00 0.00 0.00 0.012

Emotions 11.11 33.33 63.89 0.00 0.00 33.33 0.012

Sleep and energy 33.33 66.67 100.00 16.67 66.67 66.67 0.035

Severity measures 20.00 33.33 51.67 16.67 26.67 43.34 0.313

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life. hus, IU should not be considered as a natural consequence of pregnancy, especially because some strategies, such as kinesiotherapy, may be used to attenuate its symptoms.

he lack of diference in the role limitations and physical limitations domain scores observed between the NG and HG groups indicated that UI had little impact on the daily life of our study’s participants. In contrast, Kim et al. [14] found that 49% of women with a recent history of GDM, reported greater than weekly incontinence, and approximately a quarter reported incontinence that interfered with activity during and ater pregnancy.

Conclusions

Our results show that UI was highly prevalent in both NG and HG women. However, UI impact was higher on pregnant women with hyperglycemia and GDM who had poorer KHQ scores in all domains, especially general health perception, UI impact, emotions, and sleep/ energy.

he high prevalence of UI during pregnancy alone justiies investigation. Our indings, however, suggest that assessing quality of life during pregnancy can be helpful in the implementation of preventive interventions and thus reduce UI occurrence and negative impact on the quality of life of pregnant women, particularly those with hyperglycemia and GDM

Authors’ contributions

All authors contributed extensively to the work presented in this paper at all

stages, and also read and approved the inal manuscript.

Acknowledgements

To São Paulo Research Foundation – FAPESP grant number 2009/00264-2

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